Inappropriate administration of injected medications via syringe and IV tubing is a well documented and serious problem. Administering a completely wrong drug can arise from syringe swapping or mislabeling. Inappropriate drug administration can also arise from a clinician giving a drug to address one problem or to invoke a response while being unaware of a potentially serious contraindication. For instance, administering a bolus of morphine to relieve pain in a patient whose cardiovascular condition is already compromised can be fatal.
A November 1999 Institute of Medicine report states that “The medication process provides an example where implementing better systems will yield better human performance. Medication errors now occur frequently in hospitals, yet many hospitals are not making use of known systems, nor are they actively pursing new safety systems.”
There has been significant effort in developing systems that are process focused such as bar coding and radiofrequency “tagging” of drugs. Since these methods are process focused, they are inherently prone to error, even though they are an improvement to systems without such processes. Only the identification of the drug itself will insure that the proper drug is being delivered to the patient.